Bone cutting guide system for osteochondral transplantation

ABSTRACT

A bone cutting guide for preparing both donor and recipient bone, including one or more articular referencing platforms contoured to a bony surface to be prepared, fixation structure to secure the articular referencing platforms on an articular surface, cutting slots spaced apart from the articular referencing platforms at predetermined distances configured to allow the passage of a saw blade in such a way to remove a bone segment either from an allograft donor or from a graft recipient in such a way that both the removed donor and recipient grafts are of the same exact dimensions, whereby when the allograft is placed in the recipient site of the patient&#39;s joint, it completely restores the articular surface to the desired level with healthy articular cartilage from the donor.

CROSS REFERENCES TO RELATED APPLICATIONS

The present application is a continuation-in-part of U.S. patentapplication Ser. No. 14/673,636 (Pat. App. Publ. No. 2015-0272594-A1),filed Mar. 30, 2015 (Mar. 30, 2015), which is incorporated in itsentirety by reference herein, and which in turn claims the benefit ofthe priority date of U.S. Provisional Patent Application Ser. No.61/972,376, filed Mar. 30, 2014 (Mar. 30, 2014), which application isalso incorporated in its entirety by reference herein.

STATEMENT REGARDING FEDERALLY SPONSORED RESEARCH OR DEVELOPMENT

Not applicable.

THE NAMES OR PARTIES TO A JOINT RESEARCH AGREEMENT

Not applicable.

INCORPORATION BY REFERENCE OF MATERIAL SUBMITTED ON A COMPACT DISC

Not applicable.

SEQUENCE LISTING

Not applicable.

BACKGROUND OF THE INVENTION Field of the Invention

The present invention relates generally to orthopedic medical devicesand methods, and more particularly to methods and apparatus for bonetransplantation, and more particularly still to devices and techniquesfor preparing and transplanting osteochondral segments in bone using anangular cutting device attached to the surface of the articularcartilage and thus referencing corresponding bone surfaces on both thedonor and recipient sites.

Background Discussion

Current osteochondral allograft technology provides an unsatisfactorysolution to the problem of preparing large osteochondral allografts. Thestate of the art is limited to the use either of hand instruments, suchas saws and burrs or, alternatively, large coring devices. When facedwith a large bone defect, for instance one involving the entire condyle,the orthopedic surgeon must use multiple interlocking cylindrical coresto resurface the large surface area. This can be problematic because ofthe increased graft tissue necessary for an interlocking technique. Forexample, in order to resurface one femoral condyle, a surgeon mightrequire the donor allograft to include an entire distal femur with bothcondyles. The cost of such a large graft can be prohibitive to theperformance of this type of surgery. Total joint replacement is asurgical option with a long history of clinical use. However, it isassociated with serious complications such as loosening, wear, andpersistent pain. The durability of total joint replacement is limited inyoung, active patients. Currently, there is no adequate mechanism forthe transplantation of large osteochondral allografts of the hip, knee,or ankle. Improved instrumentation will facilitate improvements inpatient outcomes from these types of surgeries.

BRIEF SUMMARY OF THE INVENTION

The inventive device and method facilitates the precise preparation ofboth the donor and recipient bone in such a way that a large bonesegment can be fit at the exact position and orientation of thepreinjury tissue and in direct contact with the patient's own nativebone thus restoring the articular surface and thus the smooth functionof a joint.

In embodiments the key elements of the device are the articularreferencing platforms and device pins. The articular referencingplatforms rest on the articular surface. In such embodiments of thecurrent invention, the articular referencing platforms are contoured tothe bony surface to be prepared. Within this cutting device, there arecutting slots provided at a predetermined distance away from thearticular referencing platforms and thus the articular surface of thejoint. These cutting slots allow the passage of a saw blade in such away to remove the bone segment either from the donor graft or from therecipient in such a way that both the removed donor and recipient graftsare of the same exact dimensions. When the graft is placed in therecipient site of the patient's joint, it completely restores thearticular surface to the desired level with healthy articular cartilagefrom the donor. In order to allow for the completion of any additionalangular cuts, additional guides and fixation devices are placed on thecutting guide based on the specific needs of the procedure. In one ofdisclosed embodiments of the invention, for the preparation of a femoralcondyle, a separate attachable tower is mounted on the original cuttingjig. This attachable tower facilitates the precise cutting of thediseased femoral condyle or femoral condyle graft away from theassociated femoral trochlea. For example, once the femoral condylargraft has been applied into its recipient site it achieves initialstabilization to the bone through direct contact over a large bonysurface and through friction between the posterior condyle, the distalcondyle, and the anterior wall of the trochlea. Additional fixation isachieved with standard screws and plates as needed and as commonlypracticed in the art of orthopedic surgery. The above described guidescan be used alone or in combination to allow transplantation of eitherone or both femoral condyles. Furthermore, the guides can be utilizedwith a separate attached trochlear tower which rests on the two femoralcondylar guides and allows for recovery of the trochlea as a singleentity. Alternatively, by utilizing both condylar guides and thetrochlear tower, the entire surface of the human distal femur can betransplanted. Thus the disclosed invention allows transplantation ofeither one or both femoral condyles independently, one femoral condylewith the femoral trochlea, the femoral trochlea in isolation, orpotentially, the entire surface of the distal femur if indicated.

In the current document, we have expanded on the previous disclosures ofdevices for the preparation of the knee and disclosed additionaliterations of the device, notably for the preparation of the humanacetabulum or hip socket, femoral condyles, and femoral trochlea of theknee. For the human acetabulum, the majority of cases of hip arthritisstart in the superior weight-bearing portion of the acetabulum. As aresult, in certain cases the full resurfacing of the hip socket is notnecessary. However, there is a need for a reliable method to resurfacejust the weight-bearing portion of the acetabulum. The currentdisclosure provides two methods for performing limited resurfacing ofthe hip socket. The first of these is a modular acetabular cutting toolthat precisely contacts the articular surface of the acetabulum. Thisreferencing guide is disposed with two cutting slots or channels,oriented radially to the base of the guide, and a set height ofreference from the hemispherical articular surface of the acetabulum.The cutting slots are disposed in a radial orientation to the base ofthe guide and each contains a cutting channel. The radially orientedcutting slots allow the surgeon to cut orthogonally to the acetabularcartilage surface and references at an angle of between 30 and 150degrees to one another. An axial cutting tool is then placed on the flatsurface formed at the top of the radially oriented cutting slots. Thisaxial cutting tool is disposed with a central cutting slot for placementof a saw in order to separate the bone previously cut through the radialcutting channels of the guide. This process allows for the completeseparation of the acetabular graft of set thickness and essentiallyparallel to the articular surface at a set distance away from thecartilage. The triangular segment is removed from the donor andrecipient using either reciprocating or oscillating bone saws or acutting burr system through the three cutting slots described above (tworadial and one axial).

The second described cutting tool for the acetabulum, described here asthe monoblock acetabular cutting guide is a unitary (one-piece) cuttingblock which references off the articular surface but contains the threedescribed cutting channels within its body. It provides the advantage ofeasier application to the surface but the disadvantage of lessvisualization of the entire surface of the acetabulum.

In another embodiment, the inventive bone cutting guide is adapted forthe preparation of the femoral trochlea. It shares commonalities withother embodiments based on referencing the articular surface of thejoint to be resurfaced. Its unique characteristics are the use ofmultiple referencing pins extending through the articular side of theguide. These again serve to orient the guide at the desired distancefrom the articular surface of the joint to obtain a graft of setthickness and orientation. The unique qualities of this device are thatit provides for the harvest of the trochlea with a triangular chevronshape that leads to increased stability after transplantation, limitsthe overall thickness of the graft, which is important for graftsurvival, and by adjustment of the reference pins allows for conversionof a malformed femoral trochlea to a trochlea with normal morphology andsmooth transition to the remaining portion of the knee at the distalfemur.

From the foregoing, it will be seen that in its most essential aspect,the inventive medical device is a bone cutting guide for preparing bothdonor and recipient bone which includes: one or more articularreferencing platforms contoured to a bony surface to be prepared;fixation structure to secure the articular referencing platforms on anarticular surface; cutting slots spaced apart from the articularreferencing platforms at predetermined distances configured to allow thepassage of a saw blade in such a way to remove a bone segment eitherfrom an allograft donor or from a graft recipient in such a way thatboth the removed donor and recipient grafts are of the same exactdimensions, whereby when the allograft is placed in the recipient siteof the patient's joint, it completely restores the articular surface tothe desired level with healthy articular cartilage from the donor.

BRIEF DESCRIPTION OF SEVERAL VIEWS OF THE DRAWINGS

The invention will be better understood and objects other than those setforth above will become apparent when consideration is given to thefollowing detailed description thereof. Such description makes referenceto the annexed drawings, wherein the orientation of the viewscorresponds to the anatomical position orientations of the inventiveapparatus when installed on an acetabulum (as seen in FIGS. 10-13, and19, or on a femoral condyle (as seen in FIGS. 28-30), or when installedon a femoral trochlea (as seen in FIGS. 51-54):

FIG. 1 is a lateral right side view of the human pelvis and sacrum;

FIG. 2 is a superior (top plan) view of an embodiment of the bonecutting tool of the present invention, shown here as the modularacetabular cutting tool;

FIG. 3 is a lateral (side) view in elevation of the modular acetabularcutting tool;

FIG. 4 is an upper perspective view of the modular acetabular cuttingtool;

FIG. 5 is an anterior view of the axial cutting tool used in combinationwith the modular acetabular cutting tool in the bone cutting guidesystem;

FIG. 6 is a lateral view thereof.

FIG. 7 is a lateral view in elevation of the combined assembly of themodular acetabular cutting tool and the axial cutting tool;

FIG. 8 is a superior view of the combined assembly of the modularacetabular cutting tool and the axial cutting tool;

FIG. 9 is an anterior view of the combined assembly of the modularacetabular cutting tool and the axial cutting tool;

FIG. 10 is a lateral view of the human pelvis showing the iliac crest,the acetabulum, and the sacrum, with the modular acetabular cutting toolplaced flush against the surface of the socket;

FIG. 11 is a perspective view of the human pelvis showing the iliaccrest with the modular acetabular cutting tool placed against thesurface of the socket;

FIG. 12 is a lateral view of the human pelvis showing the iliac crestwith the combined assembly of the modular acetabular cutting tool andthe axial cutting tool;

FIG. 13 is a perspective view of the human pelvis showing the iliaccrest with the combined assembly of the modular acetabular cutting tooland the axial cutting tool affixed;

FIG. 14 is a lateral view of the human pelvis showing the iliac crest,the acetabulum, and the sacrum, shown from a viewing angle slightlysuperior to that of the view of FIG. 1;

FIG. 15 is an outer perspective view of the monoblock acetabular cuttingtool;

FIG. 16 is a lateral view of the monoblock acetabular cutting tool;

FIG. 17 is an inner perspective view of the monoblock acetabular cuttingtool;

FIG. 18 is a superior view of the monoblock acetabular cutting tool;

FIG. 19A is a lateral view of the human pelvis and the monoblockacetabular cutting tool;

FIG. 19B is the same view showing the acetabular graft to be removed;

FIG. 19C is again a lateral view of the human pelvis, this showing theactetabular cutting tool removed so as to feature the graft section tobe removed;

FIG. 19D is the same view showing the graft removed from the acetabulum;

FIG. 19E is an anterior view showing the graft removed;

FIG. 20 is an inferior right lateral perspective view of the femoralcondylar cutting guide of the present invention;

FIG. 21 is right lateral view in elevation thereof;

FIG. 22 is a superior and medial perspective view thereof;

FIG. 23 is an inferior and right lateral perspective view of theattachable tower for the femoral condylar cutting guide of the presentinvention;

FIG. 24 is a lateral (medial) perspective view thereof;

FIG. 25 is an inferior medial perspective view thereof;

FIG. 26 is a lateral view in elevation of a screw guide, including aguide positioning arm, guide body, and screw aperture;

FIG. 27 is the anterior to posterior view in elevation thereof;

FIG. 28 is an inferior lateral perspective view of the assembledinstrument complex consisting of the attachable tower interlocked withthe femoral condylar cutting guide and applied to a right human distalfemoral condyle (i.e. viewed anatomically from distal to proximal andslightly superiorly;

FIG. 29 is an inferior view in elevation thereof;

FIG. 30 is a right lateral view in elevation thereof;

FIG. 31 is a perspective view of the patient's left femur after removalof the diseased medial femoral condyle so as to form the patient'sfemoral condyle recipient site;

FIG. 32 is a lateral view of a femoral condyle osteochondral allograftafter removal from the entire distal femoral allograft;

FIG. 33 is a perspective view of the osteochondral allograft afterplacement on the distal end of the patient's femoral condyle recipientsite;

FIG. 34 is a right lateral view in elevation of symmetrical (mirrorimage) femoral condylar cutting guides applied to the end of a distalfemur taken from the same perspective as that of FIG. 29;

FIG. 35 is a front view in elevation of the symmetrical (mirror image)femoral condylar cutting guides applied to the end of the distal femur,and further including a mounted monoblock trochlear harvesting tower, aguide with placing the two trochlear cutting slots at a set distance andangle from one another and converging at a predetermined line;

FIG. 36 is an upper front right perspective view of the symmetrical(mirror image) guides applied to the end of the distal femur with themounted monoblock trochlear harvesting tower also installed;

FIG. 37 is a perspective view of an embodiment of the bone cutting guidesystem of the present invention—the trochlear cutting guide;

FIG. 38 is a lateral view of the trochlear cutting guide;

FIG. 39 is a distal view of the trochlear cutting guide showing itsdistal cylindrical channel;

FIG. 40 is a lateral view of the trochlear cutting guide;

FIG. 41 is an inferior view of the trochlear cutting guide;

FIG. 42 is a perspective view of a reference spacer;

FIG. 43 is a superior view of the trochlear cutting guide placed on adistal femoral allograft;

FIG. 44 is a lateral view thereof;

FIG. 45 is a distal perspective view thereof;

FIG. 46 is another distal view thereof, showing the trochlear cuttingguide placed on a distal femoral allograft and featuring referencespacers disposed through multiple cylindrical channels to reference thebone surface of the graft;

FIG. 47 is the same view showing the distal femoral allograft with atrochlear graft having been cut through the cutting channels andremoved;

FIG. 48 showing the removed trochlea allograft specimen shown inisolation with a non-articular chevron-shaped triangular morphology;

FIG. 49 is a distal view of a diseased femur with trochlear dysplasia;

FIG. 50 is a distal perspective view of the same diseased femur withtrochlear dysplasia;

FIG. 51 is a distal perspective view of the diseased femur with thetrochlear cutting guide installed on the abnormal dysplastic femur;

FIG. 52 is a distal view thereof slightly medial of the view of FIG. 51;

FIG. 53 is a superior view of the diseased femur with the trochlearcutting guide mounted on the abnormal dysplastic portion of the femurand showing multiple reference spacers but none referencing thedysplastic portion of the femoral trochlea;

FIG. 54A is a distal view thereof showing the diseased femur aftercutting and removal of the diseased, dysplastic segment;

FIG. 54B is the same view after removal of the trochlear guide byremoval of the holding rod and the pins passed through fixation holes;

FIG. 55 is a distal perspective view of the diseased femur after removalof the diseased, dysplastic trochlea and after removal of the trochlearguide; and

FIG. 56 is a distal perspective view of the diseased femur afterplacement of the previously obtained healthy and normally shapedallograft trochlea.

DETAILED DESCRIPTION OF THE INVENTION

Referring first to FIG. 1, there is shown a human pelvis 70, showing theiliac crest 72, the acetabulum 74, the pubis 76, the greater sciaticnotch 78, the ischium 80, the ischiopubic ramus, 82, the anteriorsuperior iliac spine 84, the anterior inferior iliac spine 86, theposterior superior iliac spine 88, the posterior inferior iliac spine90, and the sacrum 92.

As seen first in FIGS. 1-13, in an embodiment 100 the bone cutting guidesystem of the present invention, the modular acetabular cutting tool,can be adapted for use in acetabular transplantation procedures. When soadapted, the device includes a hemispherical reference guide provided inmultiple sizes between 40 and 60 mm in 1 mm increments. In the mostgeneral terms, the main cutting tool includes a hemispherical body withtwo vertical cutting slots or channels radially oriented in relation tothe perimeter of a lower rim of the hemispherical guide (thus,substantially perpendicular to the widest perimeter of the hemisphericalguide). These two cutting channels can be angled between 30 and 150degrees from one another, with an ideal angle of 90 degrees. Thechannels extend to and through two outriggers, which each include avertically oriented body with a vertically oriented cutting slot alignedwith one of the cutting channels or slots in the hemispherical body. Atthe top of the two vertical cutting towers, a planar (flat) support isestablished for placement of a second cutting tool, i.e., an axialcutting tool. The axial cutting tool is placed atop the vertical cuttingtowers. This axial cutting tool is oriented parallel to the widestperimeter of the hemispherical guide. It contains a cutting slotperpendicular in orientation to the vertical cutting extensions and isdisposed such that at the outer edge of its cutting slot, a pin hole isestablished. A metal guide pin is placed in this hole to stabilize theaxial cutting tool to the acetabular bone, but also acting as a stop tokeep the cutting saw from cutting outside the trajectory of the guidepin. The guide pins are placed in the axial cutting tool such that theyare exactly vertical to the two cutting channels of the vertical cuttingguide. In this way, once the entire assembly is applied these twocutting guides act as a stop of the saw cuts of the vertical cuttingguides as well. The vertical distance from the extension of thehorizontal cutting slot to the top of the hemisphere establishes thevertical thickness of the acetabular allograft.

The same technique for retrieval of the graft is used for removal of thediseased acetabular segment. The steps involve applying thehemispherical guide to the acetabulum, pinning the guide in place,placing the axial cutting tool on the modular acetabular cutting tool,applying guide pins to the horizontal guide, cutting through thevertical cutting paths, and cutting through the horizontal cuttingpaths. Finally, the guide is removed and the bone segment is removed,whether from the donor graft or from the patient's (recipient's)acetabulum.

Looking specifically at FIGS. 2-4, there are shown a superior (top plan)view, side view in elevation, and upper perspective view, respectively,of a modular acetabular cutting tool 100 in an embodiment of the bonecutting guide of the present invention. As seen in this view, themodular acetabular cutting tool 100 includes a hemispherical dome 102with a generally planar bottom edge 104 and a plurality of fenestrations(in this embodiment, circular) 106 through which a surgeon can confirmcomplete contact between the guide and the acetabular cartilage.Extending radially from the lower portion 108 of the hemispherical dome100 are two outriggers 110, 112, each having a vertically oriented tower114, 116, thus giving the outrigger and towers an L-shaped configurationin an embodiment, and each vertical tower in turn having verticallydisposed cutting slots or channels 118, 120 that are each aligned with avertically oriented cutting slot 122, 124, respectively, in thehemispherical dome. The cutting slots 122, 124 converge and cross at theapex 126 of the hemispherical dome and may be radially separated orangled on the dome at any of a number of angles between 30 and 150degrees, with 90 degrees a preferred angle. A saw is reciprocatedthrough the slots in the cutting towers and cutting slots to obtain awedge cut through the acetabular roof.

The towers 114, 116 of the outriggers 110, 112, each include a first setof peripheral fixation holes 128, 130, disposed on a small protrusion132, 134 near the upper end of the slots 118, 120. The fixation holesare used to hold the guide in the desired position adjacent to theacetabular rim. The vertically oriented cutting slots 118, 120 throughthe hemispherical guide extend through the outriggers. A flat uppersurface 136, 138, is established at the top of each outrigger tower forplacement of the axial cutting tool. An additional fixation hole 140,142 is disposed proximate the top of each outrigger tower. These holeshave axes parallel to fixation holes 128, 130.

FIGS. 5-6 are, respectively, an anterior view and a lateral view of theaxial cutting tool 150 used in the cutting guide assembly, while FIGS.7-9 show how the axial cutting tool is placed on the flat surfaces (136,138 in FIGS. 2-4) of the cutting towers 110, 112 of the modularacetabular cutting tool 100 to make the combined assembly.

The axial cutting tool includes an arcuate bar 152 as viewed in top planview (see FIG. 8) and includes a horizontally oriented cutting slot 154.The arcuate bar includes upper bosses 156, 158, each with fixation holes160, 162, and at least one lower boss 164 with fixation holes 166.Additional fixation holes 168, 170 may be disposed outside the ends 154a, 154 b of the horizontally disposed cutting slot 154. When the axialcutting tool is mounted on the flat surfaces 136, 138 of the cuttingtowers, the fixation holes 140, 142 disposed proximate the top of eachoutrigger tower is collinear with the additional fixation holes 168, 170outside the ends of the horizontally disposed cutting slot 154. Thisserves to firmly affix the axial cutting tool both to the bone and tothe modular acetabular cutting tool.

FIGS. 10-11 are lateral and perspective views, respectively, of thehuman pelvis showing the modular acetabular cutting tool 100 placedflush against the surface of the acetabular socket by contact of thefenestrations 106 around the guide with the cartilage of the acetabulum.The outriggers 110, 112 extend outward and upward and contain theperipheral fixation holes 128, 130, for attachment of the guide to theacetabulum. The outriggers extend outward and upward and at FIG. 11demonstrate the vertically oriented tower cutting slots 118, 120,aligned with the vertically oriented slots 122, 124 in the hemisphericalguide to obtain a wedge cut through the acetabular roof.

FIGS. 12-13 are, respectively, a lateral and a perspective view of thehuman pelvis showing the combined assembly of the modular acetabularcutting tool 100 and the axial cutting tool 150 with its superiorattachment holes 160, 162, and its horizontally disposed cutting slot154. Again, the modular acetabular cutting tool 100 is placed flushagainst the surface of the acetabular socket by contact of thefenestrations 106 around the guide with the cartilage of the acetabulum.

In another embodiment 200, the monoblock acetabular cutting guide shownin FIGS. 14-19—this embodiment again adapted for use in acetabulartransplant procedures—the device includes a unitary (one-piece) cuttingtool with both an axial cutting slot and vertical cutting slots so as toprovide cutting guides of the kind described in connection with theembodiment of FIGS. 2-13, and thus a device that facilitates the removalof osteochondral grafts from the acetabulum.

This embodiment 200 of the inventive cutting tool includes a concavesurface which approximately matches the edge of the acetabulum and aconvex hemispherical central extension that matches the contour of theacetabulum. By resting the vertical portion of this concavecomplementary surface against the rim of the acetabulum, the guide isset in its position in the horizontal plane. By placing the horizontalportion of this concave surface and its central extension against therim and the surface of the acetabulum respectively, the guide is set inits position in the vertical plane. The guide is disposed with amultitude of fixation holes on its sides as well as on its superiorsurface allowing it to be held in a stable position during thepreparation and removal of the graft segments.

The guide is disposed with two vertical cutting slots angled between 30and 150 degrees from one another. The guide is disposed with at leastone horizontal guide at its superior surface facilitating the separationof the superior segment of the graft from the donor pelvis.

FIG. 14 is a lateral view of the human pelvis shown from a viewing angleslightly superior to that of the view of FIG. 1.

FIGS. 15-18 are, respectively, an outer perspective view, a lateralview, an inner perspective view and a superior view of an embodiment 200of the acetabular cutting tool, the monoblock acetabular cutting guide.In this embodiment, the tool includes arms 202, 204, which converge at avertex 206 and are separated by an angle 208, which may be between 30and 150 degrees, but which is preferably 90 degrees. Each arm includes avertical slot 210, 212 which extends through the arm and functions as asaw blade guide. An arcuate bar 214 extends between and joins the armsand includes upper bosses 216, 218, 220, each having a fixation pin hole222, 224, 226, respectively. A medial support strut 228 (FIG. 18 only)extends from the vertex 206 to the arcuate bar 214.

Each arm 202, 204 includes a projection 230, 232 shaped to support aperipheral fixation hole 234, 236 at the outer edge of the arm as araised boss. Additional fixation pin holes 242, 244 are disposed throughtubes 246, 248 integral with the guide at the superior aspect 250 of theguide immediately above their respective vertical slots 210, 212. Ahorizontal cutting slot 252 allows the saw to be placed parallel to thesurface of the acetabulum with a set thickness based on the parametersof the guide, i.e., the vertical distance between the concave surface ofthe guide and the horizontal cutting slot and the vertical distancebetween the convex surface of the top of the vertex 206. Cutting throughsequentially through the vertical cutting slots 210, 212 followed bythrough the horizontal cutting slot enables complete separation of theacetabular graft from the rest of the acetabulum.

FIG. 19 is a lateral view of the human pelvis and acetabular cuttingtool 200 demonstrating the structural and operational elements of thedevice when installed on an acetabular socket AS for removal of either agraft AG or preparation of a graft recipient site. FIGS. 19B-19E showthe stages in the graft removal and/or recipient site preparation, asdescribed in the immediately preceding paragraph.

Referring next to FIGS. 20 through 37, there is shown another embodimentof the bone cutting guide system for osteochondral transplantation ofthe present invention.

Referring first to FIGS. 20-21, cutting guide 300 is seen to comprise acutting guide block 301 including a distal portion (in reference to thefemoral condyle to which it is applied) 303 and a posterior portion 305generally normal to the distal portion. A distal cutting slot 302 isdisposed through the distal portion 303 of the cutting guide block 301and a posterior cutting slot 304 is disposed through the posteriorportion 305. Fixation holes 306 for the guide are shown on both thedistal and posterior portions and are preferably disposed throughsemi-cylindrical bosses 306 or other structure integral with,respectively, the proximal side 307 of the distal portion and theanterior side 309 of the posterior portion. A fixation through hole 308is provided in the distal portion for mounting and securing anattachable tower (discussed more fully below). The cutting guide blockdistal and posterior portions may be generally planar on their exposedsurfaces, though such a configuration is not essential to theoperability of the assembly.

At least one condylar rail, and preferably a plurality of spaced apartand generally parallel condylar rails 310, is attached to both thedistal and posterior portions of the cutting guide block, the former,distal portion with at least one, and preferably two, cross bars 311;and the latter, posterior portion with a single strut 313. A lower crossbar 315 provides structural support proximate the lower ends of thecondylar rails and may extend so as to be contiguous with strut 313, orit may be a discrete cross-bar structure.

The condylar rails are configured with a curvature to rest on the distalfemoral cartilage contacting this surface intimately as a reference ofthe spatial location and orientation of the cartilage surface. Along thedistal aspect of the guide and disposed on the outer surfaces of thecondylar rails are one or more screw guide bosses 317 having screw guidetracks or apertures 314 disposed therethrough, into and through which ascrew guide passes and slides, such that the screw guide is disposedgenerally transversely across and in front of (distally in relation to)the condylar rails. At least one stabilization bolt hole 312, (bolt notshown) is provided through one or more of the screw guide bosses forplacement of a bolt to securing and stabilize the screw guide within thescrew guide bosses and within the screw guide track 314. The screw guideis slidably adjustable within the screw guide track for precisepositioning on the bone.

It will be seen that the condylar rails include curvature that extendsso as to provide a lower posterior rail portion 310′ and partially 310″engaging the posterior cartilage surface when in place, and similarlyinclude curvature so as to provide an anterior rail portion 310″.

It will be recognized that the cutting guide block 301 is configuredwith curvature 301′ on the condyle-engaging side (though the curvaturemay be either medial or lateral) of the cutting guide block in thecondyle capturing region of the condylar rails so as to closely engagethe distal femoral condyle when surgically placed.

Referring next to FIG. 22, which is a posterior lateral perspective viewof the cutting guide, there is shown the distal cutting slot 302 incutting guide block 301. The posterior cutting slot is shown by 304.Fixation holes 306 in the guide are shown and are seen to be throughholes. The anterior condylar rail portions 310″ rest on the anterior,distal bone surface to be cut. The screw hole 312 for stabilization ofthe screw guide is shown. The anterior condylar rail portions 310″extend so as to provide an anterior rail portion that rests on theanterior femoral condyle. The anterior cylindrical female elements 316of the cutting guide are shown disposed in the anterior edge 319 of theanterior portion 303 of the cutting guide block 301. This is the dockingor attachment site of the attachable tower cutting guide shown in FIGS.23-25.

FIG. 23 is a perspective view of the attachable tower cutting guide 400demonstrating the lateral or outer surface 401 with the entry site ofthe obliquely oriented pin holes 318 for attachment of the guide to thebone. Multiple cutting tracks 320 aligned in a generally parallel arrayand disposed at a specified angle θ (preferably between 0 and 90degrees) relative to the condylar rails when installed may be employeddepending on the specific size of the desired bony cut and the desiredanterior to posterior dimension of the femoral condylar graft to betransplanted. An anterior to posterior peg or hole or screw channel 322,is available for engaging attachable tower cutting guide to the cuttingguide block 301 by placement of a metal peg through the peg hole andinto the fixation hole 308 of the cutting guide block 301.

FIG. 24 is a lateral perspective view of the attachable tower cuttingguide 400 demonstrating the inner surface 323 with the exit site of theobliquely oriented pin holes 318 for attachment of the guide to thebone. Multiple cutting tracks 320 are again seen based on the specificsize of the desired bone cut. The inner exit site of the anterior toposterior screw channel 322, is shown on the surface 325 that engagesthe distal portion 303 of the main cutting guide block 301 by placementof a metal screw through the screw hole and into the fixation hole 308for the cutting guide block 301 of the main cutting guide 300.

FIG. 25 is an inferior perspective view of the attachable tower cuttingguide 400 demonstrating the inner surface 323 with the exit site of theobliquely oriented pin holes 318 for attachment of the attachable towercutting guide to the bone. Again, pin holes 318 are through holes andare disposed in sleeves or bosses 318′, which may be semi-cylindrical,though geometry is not critical. Multiple cutting tracks 320 are againseen, dimensions based on the dimensions of the femur being treated. Theproximal exit site of the anterior to posterior screw hole 322 is againshown. Male pedestals 324 are shown to extend from the undersurface 321of the attachable tower cutting guide for insertion into the superiorcylindrical female elements 316 of the anterior surface 319 of thedistal portion 303 of the main cutting guide block 301.

FIG. 26 is the lateral view of the screw guide 300 showing that itincludes an elongate guide positioning arm 326, a generally cylindricalscrew guide body 328, and screw aperture 330 disposed through the guidebody. The guide positioning arm 326 fits into the screw guide tracks314, seen in FIGS. 20-21. As can be seen, the cross-sectional shape ofthe guide positioning arm 326 is generally rectangular and it is sizedslightly smaller than the conforming rectangular aperture of the screwguide tracks 314 so as to slide easily and smoothly into and through thealigned screw guide tracks while minimizing proximal and distalmovement. Preferably the plane of the larger rectangular dimension 327is oriented normal to the axis 331 of the screw aperture 330, while theplane of the shorter rectangular dimension 329 is oriented generallyparallel to the same axis.

FIG. 27 is the anterior to posterior view of the screw guide, againshowing the elongate guide positioning arm 326, the guide body 328, andthe screw aperture 330. FIG. 28 is a perspective view of the entireinstrument complex—cutting guide 300 and attachable tower cutting guide400—as applied to a human distal femur DF. The main cutting guide 300 isshown with its distal cutting slot 302, and its posterior cutting slot304. Fixation holes 306 in the main cutting guide demonstrate thecontact with the femoral condyle FC for passage of the fixation pins(not shown). The condylar rails 310 rest on the anterior femoral condyleAFC up to the level of the femoral trochlea FT, and extend along theentire articular surface of the femoral condyle FC. Along the distalaspect, bolt hole 312 (bolt not shown) is provided for passage andinsertion of a stabilizing bolt for stabilizing and securing the screwguide positioning arm 326 within the screw guide track 314. The screwguide body 328, and screw aperture 330 are shown and indicate theutility of the sliding positioning arm in allowing appropriatepositioning of the screw away from the articular cartilage surface ofthe femoral condyle FC, as needed and such that fixation can be achievedin the non-articulating portion of the femoral condyle, based on thewidth of the condyle. The attachable tower guide 400 is shown anddemonstrates the multiple cutting tracks 320, available for cutting ofthe condyle-trochlear interface of the diseased distal femur or thefemoral allograft. The selected cutting track dictates theanterior-to-posterior length of the femoral graft and must be exactlymatched between the recipient and the donor to ensure appropriate sizingof the graft.

FIG. 29 is a distal view of the entire instrument complex as applied toa human distal femoral condyle FC. The femoral condylar cutting guide isshown with its condylar rails 310, resting on the entire femoral condyleFC to the level of the trochlea and extending posteriorly along thearticular surface. At the distal most aspect of the guide there is atrack 314, (not shown) for the screw guide positioning arm 326, with thebolt hole 312, (bolt not shown) for stabilization of the screw guidepositioning arm 326. The screw guide body 328, and screw aperture 330are shown. The tower cutting guide is shown and demonstrates themultiple cutting tracks, 320 available for cutting of the trochlearinterface of the femoral allograft.

FIG. 30 is a lateral view of the entire instrument complex as applied toa human distal femur. The main cutting guide is shown with its condylarrails 310, resting on the femoral condyle. At the distal most aspect ofthe guide the track for the screw guide positioning arm 326 is shown,along with the screw guide body 328. The attachable tower cutting guide400 is shown and again demonstrates the multiple cutting tracks 320available for cutting of the trochlear interface of the femoralallograft. Attached to the proximal aspect of the attachable towercutting guide, there are obliquely oriented pin holes for attachment ofthe guide to the bone 318.

FIG. 31 is a perspective view of a recipient patient's femur afterremoval of the diseased femoral condyle. Shown is the distal femoral cutedge DCEr, the trochlear cut edge TCEr, and the posterior femoralcondyle cut edge PCEr.

FIG. 32 is a lateral view of the donor's femoral condyle osteochondralallograft OA after it has been removed from the rest of the femoralcondyle graft and indicating the position of the trochlear cut TCd, thedistal femoral cut DCd, and the posterior condylar cut PCd.

FIG. 33 is a perspective view of the osteochondral allograft after ithas been placed on the distal end of the patient's distal femoralcondyle recipient site. The patient's distal femur DFCr is shown. Thecut trochlear edge TCEr is indicated as well as the posterior condylaredge PCEr.

FIG. 34 is a distal view of two mirror image (medial and lateral) guidesapplied to the end of the distal femur. They can each be stabilized totheir independent femoral condyle with an independent locking screwguide 328 a and 328 b. The trochlea can be prepared using the attachabletower cutting guide(s) as shown 400 a and 400 b.

FIG. 35 is a distal view of two mirror image cutting guides 300 a, 300b, (no labels on this figure) applied to the end of the distal femurDFCr. An alternative embodiment is shown for a singular or monoblocktrochlear guide 450 which rests on the medial and lateral guides. Thecondylar guides 300 a, 300 b are shown with their condylar rails 310 a,310 b, and bolt holes 312 a, 312 b, which in this case are holding asingle rigid connection rod 332 consisting of two attached screw guidebodies 334 in the midportion of an extended guide positioning arm 333.The rigid connection rod maintains the two mirror image guides in acollinear orientation facilitating the precision of the procedure.

The singular or monoblock trochlear guide consists of angled cuttingsurfaces 452 a and 452 b, which are disposed in angular deviationsbetween 0 degrees and 180 degrees between the two sides. The plane ofthe two cutting surfaces meet at a line oriented parallel to thearticular surface of the trochlea. The singular or monoblock trochlearguide facilitates en bloc removal of the diseased trochlea andharvesting of an identically sized osteochondral allograft trochlea.

FIG. 36 is a distal perspective view of the apparatus from FIG. 16showing the condylar guides with their condylar rails 310 a, 310 b,respectively, and corresponding bolt holes 312 a, 312 b, for holding therigid connection rod 332 with its extended guide positioning arms 333.and the singular or monoblock trochlear guide 450 with its angledcutting surfaces 452 a, 452 b. The posterior cutting slot 304 b andfixation hole 306 b of the condylar guide are also shown. Thecombination of the posterior cutting slot 304 b, distal cutting slot 306b, and trochlear cutting surfaces 452 a, 452 b facilitates the recoveryof the entire distal articular surface of the femur.

FIGS. 37-54 show another embodiment of the present invention, theseviews featuring a dedicated trochlear cutting tool 500 that allows asurgeon to recover the entire trochlea as one large segment whileleaving the medial and lateral femoral condyles untouched in order totransplant a normal healthy trochlear allograft or tissue-engineeredtrochlear implant to the matching geometry of a normal trochlea.

The embodiment of FIGS. 37-54 includes a stabilizing frame 502 havingtwo intersecting arcuate beams, a short beam 504, and a long beam 506,each with multiple cylindrical holes 508 for insertion and placement ofreference spacers 515. The reference spacers allow the cutting guide tobe precisely positioned at a set distance above the complex surface ofeither the donor or recipient trochlea. Two arcuate cutting elements510, 512, each describing approximately 180 degrees of arc are placed atthe inferior aspect of the long beam 506 and converge in a virtual lineL defined by holes 503, 505 through spaced apart distal and proximalcoaxial tubes 514, 516, respectively. The ends 518, 520 of the shortbeam 506 connect to the middle of the arcuate cutting elements 510, 512,respectively. The cutting elements also include fixation holes 522disposed through projecting bosses 524, 526, 528, 530 on the lower andupper surfaces 532, 534, 536, 538 of each cutting element, aligned(i.e., parallel to) the plane of the interior sides of the cutting slotsof their respective cutting element.

Fixation pins or screws (not shown) inserted through the fixation holesare employed to hold the trochlear cutting guide against bone both aboveand below the cutting slots 540, 542 in the respective cutting elements,the cutting slots configured for passage of a bone cutting instrumentsuch as a saw or burr. The cutting elements are placed at an angle ofbetween 45 to 180 degrees to one another in the smallest angle betweenthem allowing for removal of a bone segment as small as a small bonewedge or as large as the entire trochlea with a flat undersurface. Inmost applications an angle of approximately 120 degrees is ideal betweenthe two bone cutting slots in the cutting elements.

The aligned coaxial distal and proximal holes 503, 503 of the tubes 514,516 define a discontinuous cylindrical hole for placement of a fixationrod in the guide's distal and proximal aspects. Both the distalcylindrical hole 503 and the proximal cylindrical hole 505 are coplanarwith the planes of the converging cutting slots and allow for fixationof the guide through bone by a rod passed through the distal cylindricalhole 503, then through the femoral bone, and then through the proximalcylindrical channel 505 (rod not shown).

Referring specifically to FIGS. 38, 40-41, 43 and 53, there is shownreferencing platforms 544, 546 on a distal inner circumference of eachof the arcuate cutting elements 510, 512 that makes contact with thearticular cartilage surface ACS of the trochlea T and femoral condyle FCin order to ensure that the graft and the recipient site have an idealsurface match of their cartilage surface that the interface betweengraft and recipient site femoral condyles. The platform can becylindrical, rectangular or any polygonal shape. It can be fixed to theguide or removable. In the embodiment illustrated herein, it is integralwith the two cutting elements of the guide.

FIG. 42 is a perspective view of a reference spacer 515, preferablyconfigured generally cylindrically for easy passage through fixationholes 508. Distally, the spacer is disposed with a rounded edge 515 a toavoid injury to the articular cartilage. The spacer has a proximalexpansion 515 b which allows for handing and insertion of the spacer.The spacer has an interference fit with the cylindrical holes 508 of thetrochlear guide such that it can slide in and out but remains relativelystable during normal handling of the guide allowing a mapping of thesurface of the trochlea between the donor and recipient. In embodiments,it can have radial cutouts to enable it to insert in discreteincrements.

Looking now at FIGS. 43-46, there is shown a superior, lateral view,distal perspective, and distal view, respectively, of the trochlearcutting guide 500 with placement on a distal femoral allograft DFA. Thereferencing platforms 544, 546 on the distal inner circumference areshown. These makes contact with the articular cartilage surface of thetrochlea to ensure that the graft and the recipient site have an idealsurface match with no excessive prominence of the graft at its interfacewith the normal femoral cartilage. FIG. 44 shows the holding rod 550positioned directly on the line where the cutting planes of the cuttingelements intersect and through coaxial holes 503, 505.

FIGS. 45-46 illustrate placement of multiple reference spacers 515within the guide to reference the surface of the graft. By placement ofthese spacers the trochlea guide is rotated in the axial plane such thatit takes a symmetric thickness of bone from the medial and lateraltrochlea from the donor allograft. The spacers also allow the guide tobe positioned in line with the sulcus of the trochlea in the coronalplane. If needed, the holding rod 550 can be removed and reinsertedafter the placement of the referencing spacers.

FIG. 47 is a distal view of the trochlear cutting guide placed on thedistal femoral allograft wherein the graft G (shown in isolation in FIG.48) has been cut through the cutting channels 540, 542 of the cuttingelements 510, 512. The referencing spacers have been removed. Thetrochlear graft has been removed. The residual portion of the allograftis shown. In an alternate technique the referencing spacers can be leftin place at the set depth for each spacer defining a desired threedimensional configuration of the spacer tips. The guide can be removedwith the spacers remaining in place and can then be applied onto thesurface of the diseased trochlea to achieve a perfect surface matchbetween the donor and the recipient trochleae. This is a preferredtechnique if the diseased trochlea has a normal morphology.

FIG. 48 shows the trochlea allograft specimen G shown in isolation. Thetrochlear groove TG is shown as well as the cut segments CS cut throughthe cutting channels (542 AND 540) (not shown) intersecting at thevirtual line of the holding rod 550 (not shown).

FIGS. 49-50 are distal and distal perspective views, respectively, of adiseased femur DF which in this case has trochlear dysplasia, a diseaseprocess where there is no concavity for tracking of the patella andwhere the trochlea is instead convex in morphology—in this instance thetrochlea with a convex morphology CT is shown. The femoral condyles FCare normal.

FIGS. 51-53 are distal perspective, distal, and superior views,respectively, of the diseased femur DF with the trochlear cutting guide500 is mounted on the abnormal, dysplastic femur. The reference spacers515 disposed through the fixation holes 508 are shown with theirproximal expansions 515 b and distal rounded tips 515 a placed withinthe guide to reference the surface of the diseased trochlea. Due to themisshapen trochlea, the pins that would make contact with the diseasedportion are not filled, and only those that contact the morphologicallynormal part of the trochlea are used as reference guides. In particular,toward its peripheral edges the trochlea is normal and those referencespacers are used while more centrally they are not used. The spacersalso allow the guide to be positioned in line with the sulcus of thetrochlea in the coronal plane and to allow the optimal amount of bone tobe removed to accommodate the healthy trochlea obtained previously fromthe graft. Two cutting elements 510, 512 are placed at the inferioraspect of the guide converging in a virtual line L. The cutting elementsare disposed with fixation holes 522 for holding the guide against thenative diseased femoral bone both above and below the cutting elements.The distal cylindrical hole 503 and proximal cylindrical hole 505 (notshown) are aligned for placement of the holding rod 550. The referencingplatforms 544, 546 on the distal inner circumference are shown. Thesemake contact with the articular cartilage surface of the relativelynormal femoral condyles of the diseased knee in order to ensure that thegraft previously obtained and the recipient site have an ideal surfacematch at their transition from the trochlea to the femoral condyles. Theholding rod 550 is positioned directly on the line where the cuttingplanes of the cutting elements intersect.

FIGS. 54A and 54B are distal views of the diseased femur after removalof the diseased trochlea. The trochlear guide remains in place and isremoved by removal of the pins passed through fixation holes 522 at thebottom surface of the cutting elements and by removal of the holding rod550 that had previously been passed from the distal cylindrical hole 503through the trochlea (not visible in this view). The distal femoralcondyles DFC of the patient's femur are not affected.

FIG. 55 is a distal perspective view of the diseased femur DF afterremoval of the diseased trochlea and after removal of the trochlearguide. The cut surfaces CS converge at the line connected by the cuttingslots 540, 542 (not shown) and by the holding rod 550 (not shown). Thetwo cutting surfaces are at the same angle to one another as theparticular guide used for the recovery. The healthy distal femoralcondyles are untouched.

FIG. 56 is a distal perspective view of the diseased femur DF afterplacement of the previously obtained allograft trochlea onto therecipient site prepared using the same guide. By referencing thetrochlear surface and the distal femoral condyles, a perfect match ofthe cartilage surfaces is achieved and a smooth transition between thetrochlear graft and the patient's femoral condyles is achieved.

In the foregoing paragraphs, various preferred embodiments of theinventive bone cutting guide have been described in fulfillment of thevarious objects of the invention. It will be recognized by those withskill in the art that these embodiments are merely illustrative of theprinciples of the invention. Modifications and adaptations thereof willbe apparent those skilled in the art without departing from the spirtand scope of the invention. The above-described surgical device and thetechniques for using it can be applied to a wide variety of joints andare not limited to application in the human knee or hip. Therefore, theabove description and illustrations should not be construed as limitingthe scope of the invention, which is defined by the appended claims.

What is claimed as invention is:
 1. A cutting guide, comprising: one ormore articular referencing platforms contoured to a surface to beprepared; fixation structure to secure said articular referencingplatforms on an articular surface; cutting slots spaced apart from saidarticular referencing platforms at predetermined distances configured toallow the passage of a saw blade in such a way to remove a bone segmenteither from an allograft donor or from a graft recipient in such a waythat both the removed donor and recipient grafts are of the same exactdimensions, whereby when the allograft is placed in the recipient siteof the patient's joint, it completely restores the articular surface tothe desired level with healthy articular cartilage from the donor;wherein said one or more referencing platforms includes, (a) astabilizing frame having an arcuate short beam and an arcuate long beamintersecting said arcuate short beam at a right angle, each of saidshort beam and said long beam having multiple cylindrical holes forinsertion and placement of reference spacers to allow the cutting guideto be precisely positioned at a set distance above a complex bonesurface of either a donor or a recipient trochlea; (b) a first arcuatecutting element describing approximately 180 degrees of arc and defininga first arcuate cutting slot describing approximately 180 degrees of arcto enable passage of a reciprocating saw or a burr, and having a firstend converging at a first end of said long beam and a second endconverging at a second end of said long beam; (c) a second arcuatecutting element describing approximately 180 degrees of arc and defininga second arcuate cutting slot describing approximately 180 degrees ofarc to enable passage of a reciprocating saw or a burr, said secondarcuate cutting element having a first end converging at a first end ofsaid long beam and a second end converging at a second end of said longbeam; and (d) a first coaxial hole disposed through said first end ofsaid long beam, and a second coaxial hole disposed through said secondend of said long beam, said first and second coaxial holes coaxiallyoriented in relation to one another and defining a discontinuous holefor placement of fixation rods; wherein said short beam has a first endconnecting to said first arcuate cutting element and a second endconnecting to said second arcuate cutting element, said first and secondarcuate cutting elements disposed at an angle of between 180 and 45degrees to one another.
 2. The cutting guide of claim 1, furtherincluding fixation holes disposed on projecting bosses on lower andupper surfaces of said first and second cutting elements, wherebyfixation pins disposed through said fixation holes are generallyparallel to the plane of the interior sides of the cutting slots of thecorresponding cutting element.
 3. The cutting guide of claim 1, whereinsaid first and second coaxial holes are coplanar with converging planesof said first and second cutting slots.